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Transforming Behavioral Health Services

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Transforming Behavioral Health Services – Health Insurer – Operational and Organizational Redesign
Copyright 2013 Advanta Healthcare Partners
1
Transforming Behavioral Health Services
Health Insurer – Operational and Organizational Redesign
In order to reduce operating costs and improve customer satisfaction levels, a large
integrated national health insurance company made the decision to try to simplify and
standardize their operating processes and workflows across the multiple sites of their
national behavioral health business. The organizational transformation included
migrating to a common information systems and technology platform and redesigning
processes and procedures to establish a consistent national standard.
Historically, the behavioral health business has grown as a result of the acquisition of
multiple regional-based plans. Their expansive core network is a competitive advantage
as it offers convenient access to multiple levels of care for all members. However, as
they acquired these regional-based plans, they did not integrate them into the new
entity. This resulted in a highly matrixed and distributed delivery model with
inconsistent capabilities and service delivery across multiple disparate platforms. This
increased complexity and inconsistent communication for providers and members who
contacted the various locations of the business and decreased provider and member
satisfaction.
The behavioral health business engaged Advanta to help improve their overall
experience with call centers; provide consistent information across the organization;
provide better communication across multiple communication channels; reduce
administrative burdens; and improve claims processing. The transformation consisted of
a multi-focused initiative which included the improvement of operational processes,
process redesign, and employee and office location changes. There were multiple
individual projects within each program.

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Transforming Behavioral Health Services – Health Insurer – Operational and Organizational Redesign
Copyright 2013 Advanta Healthcare Partners
2
Advanta provided expertise and resources to fill key roles in all aspects of the project
including: overarching transformation guidance and support, program and project
management, industry and technology subject matter experts, and business-systems
analysis. As a result of the transformation initiative, the behavioral health business
successfully redesigned the organization to achieve improved customer service levels
and reduced operating costs by over $100 million.
The Client’s Challenges
The primary challenges facing the team:
 The organization consisted of multiple physical locations across the nation that
was the result of multiple business acquisitions over the past decade or so. This
structure created a lack of consistency in terms of operating processes, procedures
and practices that reduced customer service levels and increased operating costs.
 Various access channels, e.g., IVR, call center staff and web portals, were not
synchronized in terms of functionality and quality of information. The various
access channels were the responsibility of a wide range of leaders within the
business and the business’ holding company.
 The information systems enabling the business processes and procedures
varied across the behavioral health business making it difficult to create a total
business view of performance.
 There was a shortage of internal resources with experience in program and
project management for such a large organizational transformation.
The Advanta Solution
Advanta provided a range of overall program office services and individual project
implementation support for the business’ organizational transformation. The program
office services included:
 Overall strategic and business planning;
 Organizational change management and communications support;
 Risk and issue management;
 Program and project performance monitoring and reporting; and
 Business case development.
Within several of the projects, the Advanta team staffed resources to elicit and
document process models and business requirements; coordinate and integrate
business requirements across projects and with the Information Technology
Department; and produce all project-related business requirements artifacts. This
included, but was not limited to, business requirement documents and requirements
traceability matrices. Advanta staff provided data and business analysis to support the
creation of a common data set to support business operations. In addition, Advanta
provided project management for five of the projects within the initiative as well as
program management of one of the programs. In these roles, Advanta was

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Transforming Behavioral Health Services – Health Insurer – Operational and Organizational Redesign
Copyright 2013 Advanta Healthcare Partners
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accountable for the development of project workplans and driving the teams to
successfully complete tasks. Advanta provided a range of industry subject matter
experts to support various project teams. These included process modeling and
design, workload categorization and queuing, and clinical triage.
The common information systems and technology platform consisted of three key
commercially available systems: claims adjudication and management (TriZetto
Facets), knowledge management (KANA) and automated workflow (Pegasystems).
Once the redesign of the behavioral health business started, the decision was made to
utilize KANA and Pegasystems to enable specific parts of the operational redesign. To
address the lack of consistency in content and methods across the nation, KANA was
implemented as the single information repository or source-of-truth. Pegasystems
was adopted as the system to enable the movement and queuing of work to the next
available resource or Customer Service Representative (CSR). Advanta supported the
design, build and deployment of both KANA and Pegasystems.
As part of the operational and organizational redesign effort, the team:
 Provided a senior level manager with experience in Facets to lead the efforts in
the decommissioning of the multiple vendors and aid the movement towards a
common platform.
 Supported the design, build and deployment of both KANA and Pegasystems.
 Provided business case and analytical management and resources.
 Compiled and analyzed a comprehensive list of data elements from across the
behavioral health business and developed a single source-of-truth.
 Identified process workflow opportunities and developed capabilities to
support tiered levels of providers service/experience. The team reviewed and
analyzed calls and web inquiries that came in from members and providers.
 Created tiered levels of calls consisting of types of calls, how they are handled,
and the skill set needed to address the inquiries (e.g. member questions regarding
co-pays vs. clinical questions). Recommendations were made for addressing
inquiries, by identifying the correct staff with the right skillset and role for each type
of inquiry.
 Analyzed and provided recommendations for improved use of telephony and
web interactions, and Interactive Voice Response (IVR) and web portal.
The Results
As a result of the team’s support and services, Advanta assisted the behavioral health
business in successfully redesigning their organization and achieved improved
customer service levels and reduced operational costs in excess of $100 million.

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Transforming Behavioral Health Services – Health Insurer – Operational and Organizational Redesign
Copyright 2013 Advanta Healthcare Partners
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The quality and consistency of service delivery across the behavioral businesses was
improved. The number of systems and departments/organizations in addition to a
large amount of manual documentation were streamlined. Provider and member
satisfaction improved as a result of streamlined processes, reduced rework, and
increased consistency across the business. Additionally, a more effective functional
design was implemented which improved the use of shared service, outsourcing, real
estate, governance and decision making. Administrative burdens were reduced to
both providers and the behavioral health business, and faster and more accurate issue
resolution was implemented. A more accurate and consolidated data management
technology was established, which significantly reduced redundant entry and data
quality issues.
Contact Information
Bill Sheats
President
bsheats@advantapartners.com
925.984.7091 cell
925.359.3239 office